Provider Demographics
NPI:1578509725
Name:CLEMENT, KEVIN BRYAN (MD)
Entity Type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:BRYAN
Last Name:CLEMENT
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:415 S 28TH AVE
Mailing Address - Street 2:
Mailing Address - City:HATTIESBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39401-7246
Mailing Address - Country:US
Mailing Address - Phone:601-268-5630
Mailing Address - Fax:601-268-5819
Practice Address - Street 1:415 S 28TH AVE
Practice Address - Street 2:
Practice Address - City:HATTIESBURG
Practice Address - State:MS
Practice Address - Zip Code:39401-7246
Practice Address - Country:US
Practice Address - Phone:601-268-5630
Practice Address - Fax:601-268-5819
Is Sole Proprietor?:No
Enumeration Date:2006-06-22
Last Update Date:2010-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL00022961207P00000X
MS16905207QS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00123076Medicaid
MS5750556OtherAETNA
MS1353817OtherCIGNA
AL009935563Medicaid
MS00123076Medicaid
MS1353817OtherCIGNA
MS302I089122Medicare PIN